374604532-5-1-2025-08-AS-RABA-DG9R3V-20250501124033

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604532
Report Date: 05/01/2025
Date Signed: 05/01/2025 12:40:47 PM

Document Has Been Signed on 05/01/2025 12:40 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	ROJA HOUSE		FACILITY NUMBER:	374604532
ADMINISTRATOR/ DIRECTOR:	GILBO, JACKELINE		FACILITY TYPE:	735
ADDRESS:	4944 ROJA DRIVE		TELEPHONE:	(442) 888-7791
CITY:	OCEANSIDE	STATE: CA	ZIP CODE:	92057
CAPACITY: 6		CENSUS: 4	DATE:	05/01/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Administrator Alex Rodriguez		TIME VISIT/ INSPECTION COMPLETED:	12:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Rebecca Borunda conducted an unannounced Required 1-Year visit. The facility file was reviewed prior to the visit. LPA was greeted by, identified herself to, and explained the purpose of the visit with Administrator Alex Rodriguez. Administrator Jackeline Gilbo arrived during the visit. The Administrator for the facility is Jackeline Gilbo and their certificate was valid and current. The facility is licensed for a maximum capacity of 6 ambulatory clients on the first floor only. During today’s visit, the facility had a census of 4 clients, 2 of which were deemed non-ambulatory by assessment records, Clients 1 and 2. [LPA provided Administrators with an LIC811 Confidential Names List to identify C1 and C2] Administrators Gilbo and Rodriguez stated that both clients ambulated without the use of assisted devices and were able to follow staff direction to evacuate the facility in case of emergency. Administrators Gilbo and Rodriguez stated that in the case of C2, the assessment and medical records did not reflect C2's current condition and ambulatory status. LPA was also able to observe that C1 was able to ambulate without assistance and was able to respond to staff questions. LPA provided guidance regarding fire clearance requirements on a Technical Violation LIC9102TV form. During visits on 4/21/2025 and 5/1/2025, LPA toured the facility and inspected each room of the facility, including client and staff rooms, bathrooms for client and staff use, kitchen, garage, common areas, and outside space. No bodies of water were observed on the premises. LPA did not observe any aspects of delayed egress or secured perimeter. The facility was found to be clean, safe, and in good repair with no pathway obstructions. The facility’s water temperature was measured at 108.4 and 113.4 degrees Fahrenheit in common bathrooms and 114.1 degrees F in a private client bathroom. Continued on LIC809-C page…

NAME OF LICENSING PROGRAM MANAGER: Jennifer Lott
NAME OF LICENSING PROGRAM ANALYST: Rebecca A Borunda
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/01/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ROJA HOUSE	FACILITY NUMBER: 374604532
	VISIT DATE: 05/01/2025

NARRATIVE

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The facility’s internal temperature was measured at 69 and 73 degrees Fahrenheit. LPA observed locked storage for all hazardous and/or toxic chemicals and were stored separately from food supplies. LPA also observed locked storage for client medications and client and staff files. Client medications are stored in their original container and labelled. According to Alex Rodriguez, no firearms or weapons are stored on the premises. LPA observed linens and hygiene products provided to the clients that are in good repair and sufficient to meet their needs. LPA observed a minimum of a 2-day supply of perishable food and a 7-day supply of non-perishable food present at the facility. The facility refrigerator was kept at 40 degrees Fahrenheit, and the facility freezer was kept at 0 degrees Fahrenheit.

Staff present at the facility during the time of the inspection had a criminal background clearance, were associated to the facility, and had a first aid certificate. LPA reviewed multiple client and staff records. Each client record was complete and contained a signed admission agreement, medical assessment, annual reappraisal, documents regarding safeguarding personal property and cash resources, and personal rights. LPA reviewed clients’ personal and incidental money and ledger with the Administrator and did not discover any inconsistencies. Each staff file was complete and contained a personnel record, first aid certificate, fingerprint clearance and association, and a health screening. LPA spoke with staff and clients present at the facility during the time of the inspection and those interviews did not reveal any licensing or regulatory concerns.

A deficiency regarding updating client records was issued and noted on the attached LIC809-D page.

An exit interview was conducted with Administrators Alex Rodriguez and Jackeline Gilbo, whose signature below confirms receipt of a copy of this report, the LIC9102TV, the LIC811, and the Licensee Appeal Rights (LIC9058 3/22).

NAME OF LICENSING PROGRAM MANAGER: Jennifer Lott
NAME OF LICENSING PROGRAM ANALYST: Rebecca A Borunda
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/01/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/01/2025 12:40 PM - It Cannot Be Edited

Created By: Rebecca A Borunda On 05/01/2025 at 11:59 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: ROJA HOUSE	FACILITY NUMBER: 374604532
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/01/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

85068.3(a)

Modifications to Needs and Services Plan

(a) The written Needs and Services Plan specified in Section 85068.2 shall be updated as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the client's physical, mental and/or social functioning. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in that C2's medical assessment and reappraisal documents were not updated to reflect a change in condition. This poses a potential health risk to clients in care.
	POC Due Date: 05/30/2025
	Plan of Correction
1 2 3 4	During the visit, Administrator scheduled a medical appointment for C2 to obtain an updated LIC602 medical assessment document. Administrator also stated that C2 has a pending appointment for an updated appraisal (IPA) document. Administrator will submit copies of the LIC602 and IPA document to the Department by POC due date of 5/30/2025.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Jennifer Lott
NAME OF LICENSING PROGRAM MANAGER:

	Rebecca A Borunda
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/01/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2025

LIC809 (FAS) - (06/04)

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